evidence-based blog of Filippo Dibari

Posts Tagged ‘RUTF’

Corporations and the fight against hunger: why CSR won’t do

In Under-nutrition on August 12, 2013 at 6:01 am

by Steve Collins and Paul Murphy – on The Guardian Professional, Thursday 18 July 2013 10.51 BST

In addition to the many millions still suffering from acute malnutrition, over one-third of all children in developing countries globally experience chronic malnutrition – often referred to as “hidden hunger” (pdf). Aside from the inherent suffering, the devastating longer-term consequences (both for the child and ultimately for their country) are often not understood.

Progress has been made in the fight against malnutrition. The development of highly fortified nutritious pastes, ready-to-use therapeutic foods, together with community-based management has revolutionised our ability to treat severe malnutrition. These products are eaten directly from the pack, do not require mixing with water, are stable without refrigeration and are highly convenient and palatable. Combined with the innovative approach of empowering mothers by delivering nutritional care to people in their communities rather than in hospitals, these foods have resulted in dramatic improvements in treatment and prevention, with death rates cut fivefold. But the problem is too big to leave to the UN, NGOs and the public sector to resolve.

 Engaging private sector

There is an opportunity for the private sector to lead in tackling this problem but traditional models that approach the treatment and prevention of malnutrition from the perspective of corporate social responsibility or charity, are not only failing to address the problem, they are also missing major opportunities for revenue growth. Malnutrition can now be treated at real scale. However, in order to extend this approach to include prevention, we need more effective engagement with the corporate sector. The debate shouldn’t be about if, but rather about how, the private sector should engage.

We set up our company, Valid Nutrition, as a social enterprise with the specific mission of manufacturing these life saving foods exclusively in developing countries and making them more available, appealing and affordable to those who need them most. Fundamental to our vision and approach is the concept of regarding malnourished people as customers – and not just as passive beneficiaries of goodwill.

In our opinion, the reason engagement has moved so slowly is that it has been based too often on a flawed CSR viewpoint. Despite all the hyperbole, CSR tends to be peripheral in most organisations and is not woven into the fabric of the business. It’s not always transparent and there maybe strings attached. Sometimes it’s driven by a need to buy profile and even worse, CSR has been used as a type of moral counterbalance to practices that have had direct negative impacts on the poor. To make a lasting difference, we believe the prevention of malnutrition must be integrated into the core business of major food companies. Realistically, that requires shareholders to receive a tangible return. At some point, companies must be able to generate profit out of their engagement with the so-called “base of the pyramid” (the economically poorest 1 billion people on our planet). Controversial perhaps, but also rooted in realism.

So how can we align two such apparently conflicting aims – the prevention and treatment of malnutrition, and profit making?

Advantages of a business model

Ultimately, there should be no conflict. The World Bank has identifiedmalnutrition as the single greatest cause of poverty. There is strong evidence that children who receive adequate nutrition go on to have substantially increased earning power as adults [43% more according to a major study published in The Lancet, in 2008]. A lifetime of increased earning power from an initial investment of less than $100 (£66), is a massive return that has huge potential to boost consumer markets and economies. Given the vast numbers of people in this segment of the global population, investment in early child nutrition is highly economically attractive for both governments and industry alike.

Reaching those consumers however demands that we create viable business models that establish better mechanisms for engagement between public and private sectors. There are two distinct and complementary models that combine and maximise the comparative advantages of each sector; one designed to increase the efficiency, impact and reach of free or subsidised products, the second, designed to increase the availability, purchase and consumption of beneficial nutritional products by those who can afford them. Both require standards and metrics to guarantee efficacy and protect the food security and self-sufficiency of vulnerable groups. Ingredients must be procured in developing countries in a way that supports local agriculture and avoids the dumping of subsidised farm outputs on the developing world.

The first model requires public nutrition interventions targeting the very poor. The low or non-existent purchasing power of these groups means that such products must be free or heavily subsidised, funded by public bodies, manufactured by businesses willing to accept a low margin and targeted to public sector and civil society actors. Although many of the essential elements of this system are already in place, its efficacy and impact needs to be increased by better harnessing private sector capability. We need commercial engagement to expand production, reduce cost and enhance distribution of new appropriately formulated foods. We also need to link these initiatives to public sector nutritional assessment and diagnosis through the use of prescriptions or vouchers. The widespread use of mobile phones, even in the poorest communities, provides an exciting and powerful potential mechanism for related cash transfers to offset against purchase price.

The second model requires appropriately formulated consumer food products to be sold to the lower levels of the socio-economic pyramid at affordable prices. Each consumer persuaded to buy effective nutritional snacks, enhances the economic productivity of future generations and frees up vital public resources to focus on those who cannot afford even the simplest foods.

To achieve this requires innovation, courage and imagination. Although ultimately the market is attractive, private sector companies entering this space on their own, face high initial risk, especially having to accept diluted margins for a considerable period. Unfortunately, typical shareholder requirements (including from many so-called “impact investors”) preclude this sort of patience and vision.

Going beyond CSR

Many companies also fear criticism of their motives in attempting to operate commercially. Business requires encouragement to face challenges. We are convinced that we can demonstrate that suitable commercial models can align revenue generation with social impact.

We believe that to open up this market requires a new genre of businesses, free from the short-term demands of typical shareholders. Structured imaginatively to avoid dilution of corporate margins, such businesses could harness commercial sector capability through purchasing R&D and “route to market” expertise and develop suitable brands produced on a commercial basis that penetrate through the population pyramid.

Such social businesses, committed to addressing humanitarian need while also achieving a commercial return, are beginning to emerge. By combining an enterprising social vision with a disciplined business approach, many are now punching above their weight and can use their presence to leverage a much wider ethical engagement from other commercial actors.

The current model for nutritional development has failed the poor of so many developing nations. Much CSR contributes to this failure through its focus on disbursements that do nothing to harness business capability or add value to the money given. Socially orientated corporate engagement through commercial enterprises can however create a multiplier effect that both improves nutrition and ultimately fosters sustainable economic development. This in turn can stimulate agricultural activity, thereby helping to create a positive cycle that both treats and prevents undernutrition. Such an approach will increase both the social and economic returns of investment.

Enabling all children to reach their full potential depends largely on nutrition. By imaginatively broadening the scope of engagement with the private sector, we can make meaningful and sustainable progress and in so doing create a massive beneficial change for individuals, societies and economies.

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Dr Steve Collins, is a medical doctor, child nutrition expert and chairman of Valid Nutrition. Paul Murphy is Valid Nutrition’s chief executive. Prior to joining the social enterprise, he worked with Unilever in a variety of senior roles for over 27 years.

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Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial

In Under-nutrition on July 7, 2013 at 12:33 pm

by Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S.

Matern Child Nutr. 2013 Jun 18.

Abstract

Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto.

This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome.

The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group.

In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.

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Locally-Prepared Ready-to-Use Therapeutic Food for Children with Severe Acute Malnutrition: A Controlled Trial

In Under-nutrition on June 4, 2013 at 8:14 pm

by Govind Singh Thakur, HP Singhand Chhavi Patel

Indian Pediatrics – Vol. 50, March 16 2013

(download the paper)

Abstract

Objective: To compare the efficacy of locally-prepared ready-to-use therapeutic food (LRUTF) and locally-prepared F100 diet in promoting weight-gain in children with severe acute malnutrition during rehabilitation phase in hospital.

Study design: Non-randomized Controlled trial.
Setting: Pediatric ward of tertiary care public hospital in Central India.
Study period: 1 October, 2009 to 30th May, 2010.
Subjects: Children aged 6 to 60 months, diagnosed as severe acute malnutrition and hospitalized during study period.

Intervention: Random group allocation followed for selection of intervention and control cohorts. The control cohort enrolled during October 1, 2009 to January 31, 2010 received F100 while the intervention cohort enrolled during 1 February to 15 May 2010 received LRUTF. Subjects receiving either of the two therapeutic foods were temporally separated to minimize the spillover effect. The study subjects and the technician delegated for measuring weight was blinded for type of intervention.

Primary outcome variable: Rate of weight-gain/kg/day.

Results: There were 49 subjects in each group. Both groups were comparable. Rate of weight-gain was found to be (9.59±3.39 g/kg/d) in LRUTF group and (5.41 ± 1.05 g/kg/d) in locally prepared F100 group. Significant difference in rate of weight gain was observed in LRUTF group (P<0.0001; 95% CI 3.17-5.19). No serious adverse effect was observed with use of LRUTF.
Conclusion: LRUTF promotes more rapid weight-gain when compared with F100 in patients with severe acute malnutrition during rehabilitation phase.

Peanut-based ready-to-use therapeutic food: how acceptable and tolerated is it among malnourished pregnant and lactating women in Bangladesh?

In Under-nutrition on June 1, 2013 at 9:45 am

by Ali E, Zachariah R, Shams Z, Manzi M, Akter T, Alders P, Allaouna M, Delchevalerie P, Harries AD.

Matern Child Nutr. 2013 May 6

Abstract

Within a Medecins Sans Frontieres’s nutrition programme in Kamrangirchar slum, Dhaka, Bangladesh this study was conducted to assess the acceptability of a peanut-based ready-to-use therapeutic food (RUTF) – Plumpy’nut® (PPN) among malnourished pregnant and lactating women (PLW). This was a cross-sectional survey using semi-structure questionnaire that included all PLW admitted in the nutrition programme, who were either malnourished or at risk of malnutrition and who had received PPN for at least 4 weeks. A total of 248 women were interviewed of whom 99.6% were at risk of malnutrition. Overall, 212 (85%) perceived a therapeutic benefit. Despite this finding, 193 (78%) women found PPN unacceptable, of whom 12 (5%) completely rejected it after 4 weeks of intake. Reasons for unacceptability included undesirable taste (60%) and unwelcome smell (43%) – more than half of the latter was due to the peanut-based smell. Overall, 39% attributed side effects to PPN intake including nausea, vomiting, diarrhoea, abdominal distension and pain. Nearly 80% of women felt a need to improve PPN – 82% desiring a change in taste and 48% desiring a change in smell. Overall, only 146 (59%) understood the illustrated instructions on the package. Despite a perceived beneficial therapeutic effect, only two in 10 women found PPN acceptable for nutritional rehabilitation. We urge nutritional agencies and manufacturers to intensify their efforts towards developing more RUTF alternatives that have improved palatability and smell for adults and that have adequate therapeutic contents for treating malnourished PLW in Bangladesh.

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State of the art of Ready-to-Use Therapeutic Food: A tool for nutraceuticals addition to foodstuff

In Under-nutrition on June 1, 2013 at 8:25 am

by Santini A, Novellino E, Armini V, Ritieni A.

Food Chem. 2013 Oct 15;140(4):843-9

Abstract

Therapeutic foodstuff are a challenge for the use of food and functional food ingredients in the therapy of different pathologies. Ready-to-Use Therapeutic Food (RUTF) are a mixture of nutrients designed and primarily addressed to the therapy of the severe acute malnutrition. The main ingredients of the formulation are powdered milk, peanuts butter, vegetal oil, sugar, and a mix of vitamins, salts, and minerals. The potential of this food are the low percentage of free water and the high energy and nutritional density. The high cost of the powdered milk, and the food safety problems connected to the onset of toxigenic moulds on the peanuts butter, slowed down considerably the widespread and homogenous diffusion of this product. This paper presents the state of the art of RUTF, reviews the different proposed recipes, suggests some possible new formulations as an alternative of novel recipes for this promising food.

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Two charities challenge company’s patent on Plumpy’Nut

In Under-nutrition on October 18, 2012 at 2:56 pm

by Clare Dyer

from the British Medical Journal (BMJ) 2010;340:c2510

“The US patent for a peanut based food product that has transformed the treatment of acute malnutrition in Africa has come under challenge by two US not for profit organisations that say they could produce similar products more cheaply.

“The California based Mama Cares Foundation and Breedlove Foods in Texas have filed a joint suit in the US District Court in the District of Columbia to try to overturn the patent held by the French company Nutriset.

“Nutriset’s Plumpy’Nut, a blend of peanut butter, powdered milk, vegetable oil, and sugar fortified with vitamins and minerals, is said by some experts to have revolutionised aid agencies’ response to malnutrition and become the standard “ready to use therapeutic food” (RUTF).

“It achieved dramatic results in Niger in 2005. Because it doesn’t need to be mixed with water, children who would previously have to be taken to hospital can be treated much more cheaply at home.

“Nutriset and its partners around the world provide the bulk of the world’s supply, but Mike Mellace, executive director of Mama Cares, said it was poised to ship its rival Re:vive product to Africa, Honduras, South East Asia, and other regions.

“The patent lawyer Robert Chiaviello is giving his services free of charge to the two organisations. Mr Mellace said that their main claim was that the patent should not have been granted because Plumpy’Nut was not novel or unique.

“If you grab a jar of Nutella and compare it to the ingredients statement on Plumpy’Nut you’ll find that it’s virtually identical. All that they’ve done is change the mixture round and have a higher vitamin and mineral mix to get to the proper WHO specifications, which anybody could do.”

“He said that Mama Cares, a non-profit offshoot of his family snack business, had managed to reduce its costs to $0.4 (£0.27; €0.78) a unit; Plumpy’Nut costs 0.55 a unit. “If you simply took the same aid dollars you could treat 30% more children because the product is cheaper.”

“Nutriset has recently started manufacturing Plumpy’Nut in the United States, in partnership with a non-profit body called Edesia. Its network of partner manufacturers also produce Plumpy’Nut locally in Niger, Ethiopia, Malawi, the Democratic Republic of the Congo, the Dominican Republic, India, Madagascar, and Mozambique.

“The company, which has registered patents in the European Union, the US, Canada, and 32 other countries, has sent legal letters to other producers of nut based RUTFs. It was criticised in an open letter last November by the international humanitarian organisation Médecins Sans Frontières for sending a letter asserting its intellectual property rights to the Indian and Norwegian manufacturer Compact.

“Adeline Lescanne, deputy general manager of Nutriset, said: “Some may pretend they are able to produce the equivalent of Plumpy’Nut at a cheaper price, but we fear that those solutions may not be [long lasting]. What should be the goal: to have companies manufacturing an RUTF in the North or to have them helping to develop local nutrition capacities, working with local health authorities, transferring competences to the South?

“It’s interesting to see the plaintiffs working on new products. Our patent on Plumpy’Nut gave them motivation to seek something else. What is really needed are increased efforts to prevent malnutrition. There are lots of things to do in the prevention field.”

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London: HUNGER TALKS (Fri, 19th Oct 2012) – open to public

In Under-nutrition on October 1, 2012 at 8:42 am

From the Conference Brochure:

Action Against Hunger and Birkbeck University are pleased to welcome you to HUNGER TALKS, a one day event that we hope will become a regular feature in the nutrition calendar.

“The aim of HUNGER TALKS is to bring together leading voices from the frontlines of the fight against hunger.

“In this first instalment, HUNGER TALKS will look at hunger from a broad perspective; not only from a Nutrition or Food Security & Livelihoods perspective, but by exploring ways in which these two come together.

“This year’s HUNGER TALKS will focus on what it means to integrate Nutrition and Food Security & Livelihoods in the 21st century, where the opportunities lie and where the challenges may lie.

“To do so, we have invited a panel of fi very experienced and innovative speakers:

Saul Guerrero – Chair man

Abigail Perry – DFID

Stephen Spratt – Research Fellow, IDS

Mark Davies – Programme Manager Social Protection, IDS

Filippo Dibari – Valid International/UCL (Institute of Global Health)

Leena Camadoo – TWIN

Click here  for the bio of the speakers, the programme details and the location.

The participation is OPEN to anybody interested.

Development of a crossover-randomized trial method to determine the acceptability and safety of novel ready-to-use therapeutic foods (ahead of print)

In Under-nutrition on September 19, 2012 at 5:07 pm

by Dibari F, Bahwere P, Huerga H, Irena AH, Owino V, Collins S, Seal A.

Nutrition (article in press).

Abstract

Objective: To develop a method for determining the acceptability and safety of ready-to-use therapeutic foods (RUTF) before clinical trialing. Acceptability was defined using a combination of three consumption, nine safety, and six preference criteria. These were used to compare a soy/maize/sorghum RUTF (SMS-RUTFh), designed for the rehabilitation of human immunodeficiency virus/tuberculosis (HIV/TB) wasted adults, with a peanut-butter/milk-powder paste (P-RUTF; brand: Plumpy’nut) designed for pediatric treatment.

Methods: A cross-over, randomized, controlled trial was conducted in Kenya. Ten days of repeated measures of product intake by 41 HIV/TB patients, >18 y old, body mass index (BMI) 18-24 kg/m^2, 250 g were offered daily under direct observation as a replacement lunch meal. Consumption, comorbidity, and preferences were recorded.

Results: The study arms had similar age, sex, marital status, initial BMI, and middle upper-arm circumference. No carryover effect or serious adverse events were found. SMS-RUTFh energy intake was not statistically different from the control, when adjusted for BMI on day 1, and the presence of throat sores. General preference, taste, and sweetness scores were higher for SMS-RUTFh compared to the control (P < 0.05). Most consumption, safety, and preference criteria for SMS-RUTFh were satisfied except for the average number of days of nausea (0.16 versus 0.09 d) and vomiting (0.04 versus 0.02 d), which occurred with a higher frequency (P < 0.05).

Conclusion: SMS-RUTFh appears to be acceptable and can be safely clinically trialed, if close monitoring of vomiting and nausea is included. The method reported here is a useful and feasible approach for testing the acceptability of ready-to-use foods in low income countries.

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Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania

In Under-nutrition on September 1, 2012 at 3:31 pm

Bruno F Sunguya, Krishna C Poudel, Linda B Mlunde, Keiko Otsuka, Junko Yasuoka, David P Urassa, Namala P Mkopi and Masamine Jimba

Nutrition Journal 2012, 11:60 

(entire doc)

Abstract

Background

HIV/AIDS is associated with an increased burden of undernutrition among children even under antiretroviral therapy (ART). To treat undernutrition, WHO endorsed the use of Ready to Use Therapeutic Foods (RUTF) that can reduce case fatality and undernutrition among ART-naive HIV-positive children. However, its effects are not studied among ART-treated, HIV-positive children. Therefore, we examined the association between RUTF use with underweight, wasting, and stunting statuses among ART-treated HIV-positive children in Dar es Salaam, Tanzania.

Methods

This cross-sectional study was conducted from September-October 2010. The target population was 219 ART-treated, HIV-positive children and the same number of their caregivers. We used questionnaires to measure socio-economic factors, food security, RUTF-use, and ART-duration. Our outcome variables were underweight, wasting, and stunting statuses.

Results

Of 219 ART-treated, HIV-positive children, 140 (63.9%) had received RUTF intervention prior to the interview. The percentages of underweight and wasting among non-RUTF-receivers were 12.4% and 16.5%; whereas those of RUTF-receivers were 3.0% (P = 0.006) and 2.8% (P = 0.001), respectively. RUTF-receivers were less likely to have underweight (Adjusted Odd Ratio (AOR) =0.19, CI: 0.04, 0.78), and wasting (AOR = 0.24, CI: 0.07, 0.81), compared to non RUTF-receivers. Among RUTF receivers, children treated for at least four months (n = 84) were less likely to have underweight (P = 0.049), wasting (P = 0.049) and stunting (P < 0.001).

Conclusions

Among HIV-positive children under ART, the provision of RUTF for at least four months was associated with low proportions of undernutrition status. RUTF has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings in Dar es Salaam, Tanzania.

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Save the Children (NGO) about treatment of Acute Malnutrition: Minimum Reporting Package User Guidelines

In Under-nutrition on August 21, 2012 at 10:46 am

(download the entire doc)

“These minimum Reporting Package (MRP) User Guidelines are intended to outline the definitions, reporting categories and performance indicators for monitoring and reporting on three feeding programmes using the MRP software.

“The programmes are: targeted Supplementary Feeding Programmes (SFPs), Outpatient Therapeutic Programmes (OTPs) and Stabilisation Centres (SCs).

“There is also guidance on interpreting and taking action on programme performance indicators.

“The audience for the guidelines are nutrition programme coordinators and M&E staff of NGOs involved in the monitoring and reporting process.”

On this blog you can find more information about management of acute malnutrition, and ready to use foods for undernutrition treatment.
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